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Home , Antipsychotic, Aripiprazole lauroxil, Carvedilol, Dopamine (medication), Famotidine, Histamine

HIGHLIGHTS OF PRESCRIBING INFORMATION ______CONTRAINDICATIONS ______These highlights do not include all the information needed to use Known hypersensitivity to (4) ARISTADA® safely and effectively. See full prescribing information for ARISTADA®. ______WARNINGS AND PRECAUTIONS ______• Cerebrovascular Adverse Reactions in Elderly Patients with - ARISTADA® () extended-release injectable Related : Increased incidence of cerebrovascular adverse suspension, for intramuscular use reactions (e.g., , transient ischemia attack, including fatalities) Initial U.S. Approval: 2015 (5.2). • Potential for Dosing and Errors: Substitution and WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS dispensing errors between ARISTADA and ARISTADA INITIO could WITH DEMENTIA-RELATED PSYCHOSIS occur. Do not substitute ARISTADA INITIO for ARISTADA (5.3). See full prescribing information for complete . • Neuroleptic Malignant Syndrome: Manage with immediate discontinuation and close monitoring (5.4). • Elderly patients with dementia-related psychosis treated with • Tardive : Discontinue if clinically appropriate (5.5). are at an increased risk of . (5.1) • Metabolic Changes: Monitor for , dyslipidemia, and • ARISTADA is not approved for the treatment of patients with (5.6). dementia-related psychosis. (5.1) • Pathological Gambling and Other Compulsive Behaviors: Consider dose reduction or discontinuation (5.7). ______INDICATIONS AND USAGE • Orthostatic : Monitor rate and pressure and ARISTADA is an indicated for the treatment of warn patients with known cardiovascular or cerebrovascular disease, and in adults (1). risk of dehydration or syncope (5.8). • , , and : Perform complete ______DOSAGE AND ADMINISTRATION blood counts in patients with a history of a clinically significant low • Administer ARISTADA by intramuscular in the deltoid (441 (WBC) count. Consider discontinuation if clinically mg dose only) or gluteal (441 mg, 662 mg, 882 mg or 1064 mg) muscle significant decline in WBC in the absence of other causative factors by a healthcare professional (2.1). (5.10). • For patients naïve to aripiprazole, establish tolerability with oral • : Use cautiously in patients with a history of seizures or with aripiprazole prior to initiating treatment with ARISTADA (2.1). conditions that lower the threshold (5.11). • There are two options for initiating treatment with ARISTADA: • Potential for Cognitive and Motor Impairment: Use caution when . Option #1: Administer one injection of 675 mg of ARISTADA operating machinery (5.12). INITIO® and one 30 mg dose of oral aripiprazole in conjunction with the first ARISTADA injection. (2.1). ______ADVERSE REACTIONS ______. Option #2: Administer 21 consecutive days of oral aripiprazole in Most commonly observed adverse reaction with ARISTADA (incidence ≥5% conjunction with the first ARISTADA injection (2.1). and at least twice that for ) was (6.1). • ARISTADA can be initiated at a dose of 441 mg, 662 mg or 882 mg administered monthly, 882 mg dose every 6 weeks, or 1064 mg dose To report SUSPECTED ADVERSE REACTIONS, contact , every 2 months (2.1). Inc. at 1-866-274-7823 or FDA at 1-800-FDA-1088 or • Dosing regimen adjustments may be required for missed doses (2.2). www.fda.gov/medwatch. • Dose adjustments are required for 1) known CYP2D6 poor metabolizers and 2) for patients taking CYP3A4 inhibitors, CYP2D6 inhibitors, or ______USE IN SPECIFIC POPULATIONS ______CYP3A4 inducers for more than 2 weeks (2.4). • : May cause extrapyramidal and/or withdrawal symptoms in

______neonates in women exposed during the third trimester of pregnancy DOSAGE FORMS AND STRENGTHS (8.1). Extended-release injectable suspension: 441 mg, 662 mg, 882 mg or 1064 mg single-dose pre-filled syringe (3) See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.

Revised: 3/2021

FULL PRESCRIBING INFORMATION: CONTENTS* 5.12 Potential for Cognitive and Motor Impairment WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS 5.13 Body Temperature Regulation WITH DEMENTIA-RELATED PSYCHOSIS 5.14 Dysphagia 1 INDICATIONS AND USAGE 6 ADVERSE REACTIONS 2 DOSAGE AND ADMINISTRATION 6.1 Clinical Studies Experience 2.1 Recommended Dosage 6.2 Postmarketing Experience 2.2 Missed Doses 7 INTERACTIONS 2.3 Early Dosing 7.1 Drugs Having Clinically Important Interactions with 2.4 Dose Adjustments for CYP450 Considerations ARISTADA 2.5 Important Administration Instructions 7.2 Drugs Having No Clinically Important Interactions with 3 DOSAGE FORMS AND STRENGTHS ARISTADA 4 CONTRAINDICATIONS 8 USE IN SPECIFIC POPULATIONS 5 WARNINGS AND PRECAUTIONS 8.1 Pregnancy 5.1 Increased Mortality in Elderly Patients with Dementia-related 8.2 Lactation Psychosis 8.4 Pediatric Use 5.2 Cerebrovascular Adverse Reactions, Including Stroke 8.5 Geriatric Use 5.3 Potential for Dosing and Medication Errors 8.6 CYP2D6 Poor Metabolizers 5.4 Neuroleptic Malignant Syndrome 8.7 Hepatic and Renal Impairment 5.5 8.8 Other Specific Populations 5.6 Metabolic Changes 10 OVERDOSAGE 5.7 Pathological Gambling and Other Compulsive Behaviors 10.1 Human Experience 5.8 10.2 Management of Overdosage 5.9 Falls 11 DESCRIPTION 5.10 Leukopenia, Neutropenia, and Agranulocytosis 12 CLINICAL 5.11 Seizures 12.1 Mechanism of Action 1 12.2 16 HOW SUPPLIED/ STORAGE AND HANDLING 12.3 16.1 How Supplied 13 NONCLINICAL TOXICOLOGY 16.2 Storage 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 17 PATIENT COUNSELING INFORMATION 13.2 Animal Toxicology and/or Pharmacology 14 CLINICAL STUDIES *Sections or subsections omitted from the full prescribing information are not listed.

2 FULL PRESCRIBING INFORMATION

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ARISTADA is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5.1)].

1 INDICATIONS AND USAGE ARISTADA is indicated for the treatment of schizophrenia in adults [see Clinical Studies (14)].

2 DOSAGE AND ADMINISTRATION

2.1 Recommended Dosage ARISTADA is only to be administered as an by a healthcare professional. For patients who have never taken aripiprazole, establish tolerability with oral aripiprazole prior to initiating treatment with ARISTADA. Due to the half-life of oral aripiprazole, it may take up to 2 weeks to fully assess tolerability. Refer to the prescribing information of oral aripiprazole for the recommended dosage and administration of the oral formulation. There are two ways to initiate treatment with ARISTADA: • Option #1: Administer one intramuscular injection of ARISTADA INITIO 675 mg (in either the deltoid or gluteal muscle) and one dose of oral aripiprazole 30 mg in conjunction with the first ARISTADA injection.

o The first ARISTADA injection may be administered on the same day as ARISTADA INITIO or up to 10 days thereafter. See the ARISTADA INITIO prescribing information for additional information regarding administration of ARISTADA INITIO.

o Avoid injecting both ARISTADA INITIO and ARISTADA concomitantly into the same deltoid or gluteal muscle. • Option #2: Administer 21 consecutive days of oral aripiprazole in conjunction with the first ARISTADA injection. Depending on individual patient’s needs, treatment with ARISTADA can be initiated at a dose of 441 mg, 662 mg or 882 mg administered monthly, 882 mg administered every 6 weeks or 1064 mg administered every 2 months. The 441 mg, 662 mg, 882 mg and 1064 mg doses correspond to 300 mg, 450 mg, 600 mg and 724 mg of aripiprazole, respectively [see Clinical Pharmacology (12.3)].

3 Table 1: ARISTADA Dosing Frequency and Site of Injection

Dose Dosing Frequency Site of Intramuscular Injection 441 mg Monthly Deltoid or Gluteal 662 mg Monthly Gluteal 882 mg Monthly or every 6 weeks Gluteal 1064 mg Every 2 months Gluteal Use the following ARISTADA doses for patients who are stabilized on oral aripiprazole, as shown in Table 2. Table 2: ARISTADA Doses Based on Oral Aripiprazole Total Daily Dose

Oral Aripiprazole Dose Intramuscular ARISTADA Dose 10 mg per day 441 mg every month 662 mg every month 15 mg per day 882 mg every 6 weeks 1064 mg every 2 months 20 mg or higher per day 882 mg every month

In conjunction with the first ARISTADA injection, administer a single injection of ARISTADA INITIO and one dose of oral aripiprazole 30 mg, or continue treatment with oral aripiprazole for 21 consecutive days [see Recommended Dosage (2.1)]. Adjust the ARISTADA dose as needed. When making dose and dosing interval adjustments, consider the pharmacokinetics and prolonged-release characteristics of ARISTADA [see Clinical Pharmacology (12.3)].

2.2 Missed Doses When a dose of ARISTADA is missed, administer the next injection of ARISTADA as soon as possible. Depending on the time elapsed since the last ARISTADA injection, supplement the next ARISTADA injection as recommended in Table 3 below.

4 Table 3: Recommendation for Concomitant Supplementation Following Missed Doses of ARISTADA

Dose of Patient’s Last ARISTADA Injection Length of Time Since Last Injection 441 mg ≤ 6 weeks > 6 and ≤ 7 weeks > 7 weeks

662 mg ≤ 8 weeks > 8 and ≤ 12 weeks > 12 weeks

882 mg ≤ 8 weeks > 8 and ≤ 12 weeks > 12 weeks

1064 mg ≤ 10 weeks > 10 and ≤ 12 weeks > 12 weeks

Re-initiate with a Supplement with a Single Dose of ARISTADA INITIO Dosage and Administration No Single Dose of and a Single Dose of for Re-initiation of Supplementation ARISTADA INITIO Oral Aripiprazole ARISTADA Required OR 7 Days of Oral 30 mg OR supplement a Aripiprazole with 21 Days of Oral Aripiprazolea a The patient should supplement with the same dose of oral aripiprazole as when the patient began ARISTADA (see Table 2).

2.3 Early Dosing The recommended ARISTADA dosing interval is monthly for the 441 mg, 662 mg and 882 mg doses, every 6 weeks for the 882 mg dose, or every 2 months for the 1064 mg dose and should be maintained. In the event of early dosing, an ARISTADA injection should not be given earlier than 14 days after the previous injection.

2.4 Dose Adjustments for CYP450 Considerations Refer to the prescribing information for oral aripiprazole for recommendations regarding dosage adjustments due to drug interactions, for the first 21 days when the patient is taking 21 days of oral aripiprazole concomitantly with the first dose of ARISTADA. Avoid initiating ARISTADA treatment with ARISTADA INITIO in patients requiring dose adjustments. Once stabilized on ARISTADA, refer to the dosing recommendations below for patients taking strong CYP2D6 inhibitors, strong CYP3A4 inhibitors, or strong CYP3A4 inducers: • No dosage changes recommended for ARISTADA, if CYP450 modulators are added for less than 2 weeks. • Make dose changes to ARISTADA if CYP450 modulators are added for greater than 2 weeks (see Table 4).

5 Table 4: ARISTADA Dose Adjustments with Concomitant CYP450 Modulator Use

Concomitant Medicine Dose Change for ARISTADAa Reduce the dose of ARISTADA to the next lower strength. No dosage adjustment is necessary in patients taking 441 mg ARISTADA, if tolerated. Strong CYP3A4 Inhibitor For patients known to be poor metabolizers of CYP2D6: Reduce dose to 441 mg from 662 mg, 882 mg, or 1064 mg. No dosage adjustment is necessary in patients taking 441 mg ARISTADA, if tolerated. Reduce the dose of ARISTADA to the next lower strength. No dosage adjustment is necessary in patients taking 441 mg ARISTADA, if tolerated. Strong CYP2D6 Inhibitor For patients known to be poor metabolizers of CYP2D6: No dose adjustment required. Both Strong CYP3A4 Avoid use for patients at 662 mg, 882 mg, or 1064 mg dose. No dosage Inhibitor and Strong adjustment is necessary in patients taking 441 mg ARISTADA, if tolerated. CYP2D6 Inhibitor No dose adjustment for 662 mg, 882 mg, or 1064 mg dose; increase the 441 CYP3A4 Inducers mg dose to 662 mg. a For the 882 mg dose administered every 6 weeks and the 1064 mg administered every 2 months, the next lower strength should be 441 mg administered monthly.

2.5 Important Administration Instructions The contains a syringe containing ARISTADA sterile aqueous extended-release injectable suspension and 2 or 3 safety needles depending on dose (a 2-inch 20 gauge needle with yellow needle hub, a 1 ½-inch 20 gauge needle with yellow needle hub, and a 1-inch 21 gauge needle with green needle hub (441 mg kit only)) for intramuscular injection. All materials should be stored at room temperature.

A | 5 mL syringe containing ARISTADA sterile aqueous extended-release injectable suspension B | 20 gauge needle, 2-inch with yellow needle hub C | 20 gauge needle, 1½-inch with yellow needle hub

6 D | 21 gauge needle, 1-inch with green needle hub

1. TAP and vigorously SHAKE the syringe.

1a. Tap the syringe at least 10 times to dislodge any material which may have settled. 1b. Shake the syringe vigorously for a minimum of 30 seconds to ensure a uniform suspension. If the syringe is not used within 15 minutes, shake again for 30 seconds. 2. SELECT the injection needle. 2a. Select injection site. 2b. Select needle length based on injection site. For patients with a larger amount of subcutaneous tissue overlaying the injection site muscle, use the longer of the needles provided. Table 5: Injection Site and Associated Needle Length Injection Site Needle Length 441 mg dose Deltoid 21 gauge, 1-inch or 20 gauge, 1½-inch Gluteal 20 gauge, 1½-inch or 20 gauge, 2-inch 662 mg dose Gluteal 20 gauge, 1½-inch or 20 gauge, 2-inch 882 mg dose Gluteal 20 gauge, 1½-inch or 20 gauge, 2-inch 1064 mg dose Gluteal 20 gauge, 1½-inch or 20 gauge, 2-inch [see Dosage and Administration (2.1)] 3. ATTACH the injection needle. Attach the appropriate needle securely with a clockwise twisting motion. Do NOT overtighten. Overtightening could lead to needle hub cracking.

7

4. PRIME the syringe to remove air. 4a. Bring the syringe into upright position and tap the syringe to bring air to the top.

4b. Depress the plunger rod to remove air until a few drops are released. It is normal to see small air bubbles remaining in the syringe.

8 5. Inject in a RAPID and CONTINUOUS manner. Product requires a RAPID injection. Do not hesitate. Administer the entire content intramuscularly. Do not inject by any other route.

6. DISPOSE of the needle. Cover the needle by pressing the safety device. Dispose of used and unused items in a proper waste container.

3 DOSAGE FORMS AND STRENGTHS ARISTADA is a white to off-white aqueous extended-release injectable suspension provided in a single-dose pre-filled syringe. ARISTADA is available as described in Table 6. Table 6: Presentations of ARISTADA

Dose Strength Volume Inject Intramuscularly Color Label 441 mg 1.6 mL Deltoid or Gluteal Muscle Light Blue 662 mg 2.4 mL Gluteal Muscle Only Green 882 mg 3.2 mL Gluteal Muscle Only Burgundy 1064 mg 3.9 mL Gluteal Muscle Only Dark Blue

4 CONTRAINDICATIONS ARISTADA is contraindicated in patients with a known hypersensitivity reaction to aripiprazole. Hypersensitivity reactions have ranged from pruritus/urticaria to [see Adverse Reactions (6)].

9 5 WARNINGS AND PRECAUTIONS

5.1 Increased Mortality in Elderly Patients with Dementia-related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the appeared to be either cardiovascular (e.g., , sudden death) or infectious (e.g., ) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. ARISTADA is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning, Warnings and Precautions (5.2)].

5.2 Cerebrovascular Adverse Reactions, Including Stroke In placebo-controlled trials with , aripiprazole, and in elderly patients with dementia, there was a higher incidence of cerebrovascular adverse reactions (cerebrovascular accidents and transient ischemic attacks) including fatalities compared to placebo-treated patients. ARISTADA is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning, Warnings and Precautions (5.1)].

5.3 Potential for Dosing and Medication Errors Medication errors, including substitution and dispensing errors, between ARISTADA and ARISTADA INITIO could occur. ARISTADA INITIO is for single administration in contrast to ARISTADA which is administered monthly, every 6 weeks, or every 8 weeks [see Dosage and Administration (2.1)]. Do not substitute ARISTADA INITIO for ARISTADA because of differing pharmacokinetic profiles [see Clinical Pharmacology (12.3)].

5.4 Neuroleptic Malignant Syndrome A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) may occur in association with antipsychotic drugs, including ARISTADA. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (irregular pulse or , , diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine phosphokinase, myoglobinuria (), and acute renal failure. The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to identify cases in which the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic , etc.) and untreated or inadequately treated

10 extrapyramidal (EPS). Other important considerations in the differential diagnosis include central toxicity, heat stroke, drug fever, and primary central pathology. The management of NMS should include: (1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; (2) intensive symptomatic treatment and medical monitoring; and (3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for uncomplicated NMS. If a patient appears to require antipsychotic drug treatment after recovery from NMS, reintroduction of drug therapy should be closely monitored, since recurrences of NMS have been reported.

5.5 Tardive Dyskinesia A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs. Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to predict which patients will develop the syndrome. Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown. The risk of developing tardive dyskinesia and the likelihood that it will become irreversible appear to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase, but the syndrome can develop after relatively brief treatment periods at low doses, although this is uncommon. Tardive dyskinesia may remit, partially or completely, if antipsychotic treatment is withdrawn. Antipsychotic treatment itself may suppress (or partially suppress) the signs and symptoms of the syndrome and may thus mask the underlying process. The effect of symptomatic suppression on the long-term course of the syndrome is unknown. Given these considerations, ARISTADA should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients who suffer from a chronic illness that is known to respond to antipsychotic drugs. In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically. If signs and symptoms of tardive dyskinesia appear in a patient treated with ARISTADA drug discontinuation should be considered. However, some patients may require treatment with ARISTADA despite the presence of the syndrome.

5.6 Metabolic Changes Atypical antipsychotic drugs have been associated with metabolic changes that include hyperglycemia/ mellitus, dyslipidemia, and weight gain. While all drugs in the class have been shown to produce some metabolic changes, each drug has its own specific risk profile.

11 Hyperglycemia/ Diabetes Mellitus Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical . There have been reports of hyperglycemia in patients treated with oral aripiprazole. Assessment of the relationship between atypical antipsychotic use and abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse events is not completely understood. However, epidemiological studies suggest an increased risk of hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including , polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients require continuation of anti-diabetic treatment despite discontinuation of the suspect drug. In the long-term, open-label schizophrenia study with ARISTADA, 14% of patients with normal hemoglobin A1c (<5.7%) at baseline developed elevated levels (≥5.7%) post-baseline. Dyslipidemia Undesirable alterations in have been observed in patients treated with atypical antipsychotics. In the long-term, open-label schizophrenia study with ARISTADA, shifts in baseline fasting total cholesterol from normal (<200 mg/dL) to high (≥240 mg/dL) were reported in 1% of patients; shifts in baseline fasting LDL cholesterol from normal (<100 mg/dL) to high (≥160 mg/dL) were reported in 1% of patients; and shifts in baseline fasting from normal (<150 mg/dL) to high (≥200 mg/dL) were reported in 8% of patients. In the same study, shifts in baseline fasting total cholesterol from borderline (≥ 200 mg/dL and <240 mg/dL) to high (≥240 mg/dL) were reported in 15% of patients; shifts in baseline fasting LDL cholesterol from borderline (≥100 mg/dL and <160 mg/dL) to high (≥160 mg/dL) were reported in 8% of patients; and shifts in baseline fasting triglycerides from borderline (≥150 mg/dL and <200 mg/dL) to high (≥200 mg/dL) were reported in 35% of patients. In addition, the proportion of patients with shifts in fasting HDL cholesterol from normal (≥40 mg/dL) to low (<40 mg/dL) was reported in 15% of patients. Weight Gain Weight gain has been observed with atypical antipsychotic use. Clinical monitoring of weight is recommended. The proportion of adult patients with weight gain ≥7% of body weight is presented in Table 7.

12 Table 7: Proportion of Adult Patients with Shifts in Weight in the 12-Week, Placebo-Controlled, Fixed-Dose Schizophrenia Trial

ARISTADA Placebo 441 mg 882 mg N = 207 N = 207 N = 208 (%) (%) (%) Weight Gain ≥7% increase from baseline 6 10 9

5.7 Pathological Gambling and Other Compulsive Behaviors Post-marketing case reports suggest that patients can experience intense urges, particularly for gambling, and the inability to control these urges while taking aripiprazole. Other compulsive urges, reported less frequently include: sexual urges, shopping, eating or binge eating, and other impulsive or compulsive behaviors. Because patients may not recognize these behaviors as abnormal, it is important for prescribers to ask patients or their specifically about the development of new or intense gambling urges, compulsive sexual urges, compulsive shopping, binge or compulsive eating, or other urges while being treated with aripiprazole. It should be noted that impulse-control symptoms can be associated with the underlying disorder. In some cases, although not all, urges were reported to have stopped when the dose was reduced or the medication was discontinued. Compulsive behaviors may result in harm for the patient and others if not recognized. Consider dose reduction or stopping the medication if a patient develops such urges.

5.8 Orthostatic Hypotension

Aripiprazole may cause orthostatic hypotension, perhaps due to its α1- antagonism. Associated adverse reactions related to orthostatic hypotension can include , lightheadedness and tachycardia. Generally, these risks are greatest at the beginning of treatment and during dose escalation. Patients at increased risk of these adverse reactions or at increased risk of developing complications from hypotension include those with dehydration, , treatment with antihypertensive medication, history of (e.g., heart failure, , ischemia, or conduction abnormalities), history of cerebrovascular disease, as well as patients who are antipsychotic-naïve. In such patients, consider using a lower starting dose, and monitor orthostatic vital signs. Orthostatic hypotension was reported for one patient in the ARISTADA 882 mg group (0.5%) and no patients in the ARISTADA 441 mg and placebo groups in the 12-week schizophrenia efficacy study [see Clinical Studies (14)]. In the long-term open-label schizophrenia study, orthostatic hypotension was reported for 1 (0.2%) patient treated with ARISTADA. Orthostatic hypotension was defined as a decrease in systolic blood pressure ≥20 mmHg accompanied by an increase in ≥25 bpm when comparing standing to supine values.

13 5.9 Falls Antipsychotics including ARISTADA may cause , postural hypotension, or motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries. For patients with diseases, conditions, or that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic treatment and recurrently for those patients on long-term antipsychotic therapy.

5.10 Leukopenia, Neutropenia, and Agranulocytosis In clinical trials and/or postmarketing experience, events of leukopenia and neutropenia have been reported temporally related to antipsychotic agents. Agranulocytosis has also been reported. Possible risk factors for leukopenia/neutropenia include pre-existing low white blood cell count (WBC)/absolute count (ANC) and history of drug-induced leukopenia/neutropenia. In patients with a history of a clinically significant low WBC/ANC or drug-induced leukopenia/neutropenia, perform a (CBC) frequently during the first few months of therapy. In such patients, consider discontinuation of ARISTADA at the first sign of a clinical significant decline in WBC in the absence of other causative factors. Monitor patients with clinically significant neutropenia for fever or other symptoms or signs of infection and treat promptly if such symptoms or signs occur. Discontinue ARISTADA in patients with severe neutropenia (absolute neutrophil count <1000/mm3) and follow their WBC until recovery.

5.11 Seizures As with other antipsychotic drugs, use ARISTADA cautiously in patients with a history of seizures or with conditions that lower the seizure threshold. Conditions that lower the seizure threshold may be more prevalent in a population of 65 years or older.

5.12 Potential for Cognitive and Motor Impairment ARISTADA, like other antipsychotics, has the potential to impair judgment, thinking or motor skills. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that therapy with ARISTADA does not affect them adversely.

5.13 Body Temperature Regulation Disruption of the body’s ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing ARISTADA for patients who will be experiencing conditions which may contribute to an elevation in core body temperature, (e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration).

5.14 Dysphagia Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. ARISTADA and other antipsychotic drugs should be used cautiously in patients at risk for .

14 6 ADVERSE REACTIONS The following are discussed in more details in other sections of the labeling: • Increased Mortality in Elderly Patients with Dementia-related Psychosis [see Boxed Warning, Warnings and Precautions (5.1)] • Cerebrovascular Adverse Reactions, Including Stroke [see Boxed Warning, Warnings and Precautions (5.2)] • Neuroleptic Malignant Syndrome [see Warnings and Precautions (5.4)] • Tardive Dyskinesia [see Warnings and Precautions (5.5)] • Metabolic Changes [see Warnings and Precautions (5.6)] • Pathological Gambling and Other Compulsive Behaviors [see Warnings and Precautions (5.7)] • Orthostatic Hypotension [see Warnings and Precautions (5.8)] • Falls [see Warnings and Precautions (5.9)] • Leukopenia, Neutropenia, and Agranulocytosis [see Warnings and Precautions (5.10)] • Seizures [see Warnings and Precautions (5.11)] • Potential for Cognitive and Motor Impairment [see Warnings and Precautions (5.12)] • Body Temperature Regulation [see Warnings and Precautions (5.13)] • Dysphagia [see Warnings and Precautions (5.14)]

6.1 Clinical Studies Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. ARISTADA Patient Exposure ARISTADA has been evaluated for safety in 1180 adult patients in clinical trials in schizophrenia. Commonly Observed Adverse Reactions The most common adverse reaction (incidence ≥5% and at least twice the rate of placebo in patients treated with ARISTADA) was akathisia. Adverse Reactions Occurring at an Incidence of 2% or More in ARISTADA-Treated Patients Adverse reactions associated with the use of ARISTADA (incidence of 2% or greater, rounded to the nearest percent and ARISTADA incidence greater than placebo) that occurred are shown in Table 8.

15 Table 8: Adverse Reaction in 2% or More of ARISTADA-Treated Patients and That Occurred at Greater Incidence than in the Placebo-Treated Patients in the 12-Week, Placebo-Controlled, Fixed-Dose Schizophrenia Trial

Aripiprazole Lauroxil Placebo 441 mg 882 mg Adverse Reaction System Organ Class N=207 N=207 N=208 Preferred Term (%) (%) (%) General disorders and administration site conditions Injection site pain 2 3 4 Investigations Increased weight 1 2 2 Increased blood creatine phosphokinase 0 2 1 Nervous system disorders Akathisia 4 11 11 3 3 5 Psychiatric disorders 2 3 4 Restlessness 1 3 1 In an open label pharmacokinetic study, the adverse reactions associated with the use of 441 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months were similar across the dose groups. Injection Site Reactions Injection site reactions were reported by 4% of patients treated with 441 mg ARISTADA and 5% of patients treated with 882 mg ARISTADA compared to 2% of patients treated with placebo. Most of these were injection site pain (3%, 4% and 2% in the 441 mg ARISTADA, 882 mg ARISTADA and placebo groups, respectively) and most were associated with the first injection, and decreased with each subsequent injection to less than or equal to 1% for both doses of ARISTADA and placebo. Other injection site reactions (induration, swelling and redness) occurred at less than 1%. In an open label pharmacokinetic study evaluating 441 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months, injection site reactions were similar across the dose groups. In the 12-week schizophrenia efficacy study [see Clinical Studies (14)], for ARISTADA-treated patients, the incidence of other EPS-related events, excluding akathisia and restlessness, was 5% and 7% for patients on 441 mg and 882 mg, respectively, versus 4% for placebo-treated patient (Table 9).

16 Table 9: Incidence of EPS Compared to Placebo

ARISTADA Placebo 441 mg 882 mg N=207 N=207 N=208 Adverse Reaction Term (%) (%) (%) Akathisia 4 11 11 Restlessness 1 3 1 Other EPS 4 5 7 1 2 2 3 3 4 Dystonia Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups. Other Adverse Reactions Observed in Clinical Studies The following listing does not include reactions: 1) already listed in previous tables or elsewhere in labeling, 2) for which a drug cause was remote, 3) which were so general as to be uninformative, 4) which were not considered to have significant clinical implications, or 5) which occurred at a rate equal to or less than placebo. Cardiac – pectoris, tachycardia, palpitations Gastrointestinal disorders – , dry mouth General disorders – asthenia Musculoskeletal – muscular weakness Nervous system disorders – dizziness Psychiatric disorders – , Adverse Reactions Reported in Clinical Trials with Oral Aripiprazole The following is a list of additional adverse reactions that have been reported in clinical trials with oral aripiprazole and not reported above for ARISTADA. Blood and Lymphatic System Disorders: thrombocytopenia Cardiac Disorders: , atrial flutter, cardiorespiratory arrest, atrioventricular block, , myocardial ischemia, myocardial infarction, cardiopulmonary failure Eye Disorders: photophobia, diplopia

17 Gastrointestinal Disorders: gastroesophageal reflux disease General Disorders and Administration Site Conditions: peripheral edema, chest pain, face edema Hepatobiliary Disorders: hepatitis, Disorders: hypersensitivity Injury, Poisoning, and Procedural Complications: fall, heat stroke Investigations: weight decreased, hepatic increased, blood glucose increased, blood lactate dehydrogenase increased, gamma glutamyl transferase increased, blood increased, blood urea increased, blood creatinine increased, blood increased, electrocardiogram QT prolonged, glycosylated hemoglobin increased and Nutrition Disorders: , , , Musculoskeletal and Disorders: muscle tightness, rhabdomyolysis, mobility decreased Nervous System Disorders: memory impairment, cogwheel rigidity, hypokinesia, myoclonus, bradykinesia, akinesia, coordination abnormal, speech disorder, choreoathetosis Psychiatric Disorders: , loss of , , libido increased, anorgasmia, tic, homicidal ideation, , sleep walking Renal and Urinary Disorders: , nocturia Reproductive System and Disorders: , gynaecomastia, menstruation irregular, , breast pain, Respiratory, Thoracic, and Mediastinal Disorders: nasal congestion, dyspnea Skin and Subcutaneous Tissue Disorders: rash, hyperhidrosis, pruritus, photosensitivity reaction, alopecia, urticaria Vascular Disorders: hypotension,

6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of oral aripiprazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or to establish a causal relationship to drug exposure: occurrences of allergic reaction (anaphylactic reaction, , laryngospasm, pruritus/urticaria, or oropharyngeal spasm), pathological gambling, hiccups, blood glucose fluctuation, , and drug reaction with and systemic symptoms (DRESS).

18 7 DRUG INTERACTIONS

7.1 Drugs Having Clinically Important Interactions with ARISTADA Table 10: Clinically Important Drug Interactions with ARISTADA Strong CYP3A4 Inhibitors and CYP2D6 Inhibitors Clinical Impact: The concomitant use of oral aripiprazole with strong CYP3A4 or CYP2D6 inhibitors increased the exposure of aripiprazole compared to the use of oral aripiprazole alone [see Clinical Pharmacology (12.3)]. Intervention: With concomitant use of ARISTADA with a strong CYP3A4 inhibitor or CYP2D6 inhibitor for more than 2 weeks, reduce the ARISTADA dose [see Dosage and Administration (2.4)]. Examples: , , , , Strong CYP3A4 Inducers Clinical Impact: The concomitant use of oral aripiprazole and decreased the exposure of aripiprazole compared to the use of oral aripiprazole alone [see Clinical Pharmacology (12.3)]. Intervention: With concomitant use of ARISTADA with a strong CYP3A4 inducer for more than 2 weeks consider increasing the ARISTADA dose [see Dosage and Administration (2.4)]. Examples: carbamazepine, rifampin Antihypertensive Drugs Clinical Impact: Due to its alpha adrenergic antagonism, aripiprazole has the potential to enhance the effect of certain antihypertensive agents. Intervention: Monitor blood pressure and adjust dose accordingly [see Warnings and Precautions (5.8)]. Examples: , lisinopril, Clinical Impact: The intensity of sedation was greater with the combination of oral aripiprazole and as compared to that observed with aripiprazole alone. The orthostatic hypotension observed was greater with the combination as compared to that observed with lorazepam alone [see Warnings and Precautions (5.8)]. Intervention: Monitor sedation and blood pressure. Adjust dose accordingly.

Example: lorazepam

7.2 Drugs Having No Clinically Important Interactions with ARISTADA Based on pharmacokinetic studies with oral aripiprazole, no dosage adjustment of ARISTADA is required when administered concomitantly with , , or [see Clinical Pharmacology (12.3)]. In addition, no dosage adjustment is necessary for substrates of CYP2D6 (e.g., , fluoxetine, paroxetine, or ), CYP2C9 (e.g., warfarin), CYP2C19 (e.g., , warfarin, ), or CYP3A4 (e.g., dextromethorphan) when co-administered with ARISTADA. Additionally, no dosage adjustment is necessary for valproate, lithium, , or when co-administered with ARISTADA [see Clinical Pharmacology (12.3)].

19 8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ARISTADA during pregnancy. For more information, contact the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or visit http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/. Risk Summary Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. Limited published data on aripiprazole use in pregnant women are not sufficient to inform any drug-associated risks for birth defects or miscarriage. No teratogenicity was observed in animal reproductive studies with intramuscular administration of aripiprazole lauroxil to rats and rabbits during organogenesis at doses up to 5 and 15 times, respectively, the maximum recommended human dose (MRHD) of 1064 mg based on body surface area (mg/m2). However, aripiprazole caused developmental toxicity and possible teratogenic effects in rats and rabbits [see Data]. The background risk of major birth defects and miscarriage for the indicated population are unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized is 2-4% and 15-20%, respectively. Advise pregnant women of the potential risk to a fetus. Clinical Considerations Fetal/Neonatal Adverse Reactions Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, , somnolence, respiratory distress and feeding disorder have been reported in neonates who were exposed to antipsychotic drugs during the third trimester of pregnancy. These symptoms have varied in severity. Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately. Some neonates recover within hours or days without specific treatment; others required prolonged hospitalization. Data Animal Data for Aripiprazole Lauroxil Aripiprazole lauroxil did not cause adverse developmental or maternal effects in rats or rabbits when administered intramuscularly during the period of organogenesis at doses of 18, 49, or 144 mg/animal in pregnant rats which are approximately 0.6 to 5 times the MRHD of 1064 mg on mg/m2 basis, and at doses of 241, 723, and 2893 mg/animal in pregnant rabbits which are approximately 1 to 15 times the MRHD on mg/m2 basis. However, aripiprazole caused developmental toxicity and possible teratogenic effects in rats and rabbits [see Data below]. Animal Data for Aripiprazole Pregnant rats were treated with oral doses of 3, 10, and 30 mg/kg/day which are approximately 1 to 10 times the oral MRHD of 30 mg/day on mg/m2 basis of aripiprazole during the period of

20 organogenesis. Treatment at the highest dose caused a slight prolongation of gestation and delay in fetal development, as evidenced by decreased fetal weight, and undescended testes. Delayed skeletal ossification was observed at 3 and 10 times the oral MRHD on mg/m2 basis. At 3 and 10 times the oral MRHD on mg/m2 basis, delivered offspring had decreased body weights. Increased incidences of hepatodiaphragmatic nodules and diaphragmatic hernia were observed in offspring from the highest dose group (the other dose groups were not examined for these findings). A low incidence of diaphragmatic hernia was also seen in the fetuses exposed to the highest dose. Postnatally, delayed vaginal opening was seen at 3 and 10 times the oral MRHD on mg/m2 basis and impaired reproductive performance (decreased fertility rate, corpora lutea, implants, live fetuses, and increased post-implantation loss, likely mediated through effects on female offspring) along with some maternal toxicity were seen at the highest dose; however, there was no evidence to suggest that these developmental effects were secondary to maternal toxicity. In pregnant rabbits treated with oral doses of 10, 30, and 100 mg/kg/day which are 2 to 11 times human exposure at the oral MRHD based on AUC and 6 to 65 times the oral MRHD on mg/m2 basis of aripiprazole during the period of organogenesis decreased maternal food consumption and increased abortions were seen at the highest dose as well as increased fetal mortality. Decreased fetal weight and increased incidence of fused sternebrae were observed at 3 and 11 times the oral MRHD based on AUC. In rats treated with oral doses of 3, 10, and 30 mg/kg/day which are 1 to 10 times the oral MRHD on mg/m2 basis of aripiprazole perinatally and postnatally (from day 17 of gestation through day 21 postpartum), slight maternal toxicity and slightly prolonged gestation were seen at the highest dose. An increase in stillbirths and decreases in pup weight (persisting into adulthood) and survival were also seen at this dose.

8.2 Lactation Risk Summary Aripiprazole is present in human breast milk; however, there are insufficient data to assess the amount in human milk, the effects on the breastfed , or the effects on milk production. The development and health benefits of should be considered along with the mother’s clinical need for ARISTADA and any potential adverse effects on the breastfed infant from ARISTADA or from the underlying maternal condition.

8.4 Pediatric Use Safety and effectiveness of ARISTADA in patients <18 years of age have not been evaluated.

8.5 Geriatric Use Safety and effectiveness of ARISTADA in patients >65 years of age have not been evaluated. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ARISTADA is not approved for the treatment of patients with dementia- related psychosis [see Warnings and Precautions (5.1, 5.2)].

21 8.6 CYP2D6 Poor Metabolizers Dosage adjustment is recommended in known CYP2D6 poor metabolizers due to high aripiprazole concentrations. Approximately 8% of Caucasians and 3-8% of Black/ cannot metabolize CYP2D6 substrates and are classified as poor metabolizers (PM) [see Dosage and Administration (2.4), Clinical Pharmacology (12.3)].

8.7 Hepatic and Renal Impairment No dosage adjustment for ARISTADA is required based on a patient’s hepatic function (mild to severe hepatic impairment, Child-Pugh score between 5 and 15), or renal function (mild to severe renal impairment, glomerular filtration rate between 15 and 90 mL/minute) [see Clinical Pharmacology (12.3)].

8.8 Other Specific Populations No dosage adjustment for ARISTADA is required on the basis of a patient’s sex, race, or smoking status [see Clinical Pharmacology (12.3)].

10 OVERDOSAGE 10.1 Human Experience Common adverse reactions (reported in at least 5% of all overdose cases) reported with oral aripiprazole overdosage (alone or in combination with other substances) include , somnolence, and tremor. Other clinically important signs and symptoms observed in one or more patients with aripiprazole overdoses (alone or with other substances) include acidosis, aggression, aspartate aminotransferase increased, atrial fibrillation, bradycardia, coma, confusional state, convulsion, blood creatine phosphokinase increased, depressed level of consciousness, hypertension, hypokalemia, hypotension, lethargy, loss of consciousness, QRS complex prolonged, QT prolonged, pneumonia aspiration, respiratory arrest, , and tachycardia.

10.2 Management of Overdosage In case of overdosage, call the Poison control center immediately at 1-800-222-1222.

11 DESCRIPTION ARISTADA contains aripiprazole lauroxil, an atypical antipsychotic. The chemical name of aripiprazole lauroxil is 7-{4-[4-(2,3-dichlorophenyl)-piperazin-1- yl]butoxy}-2-oxo-3,4-dihydro-2H-quinolin-1-yl)methyl dodecanoate. The empirical formula is C36H51Cl2N3O4 and its molecular weight is 660.7 g/mol. The chemical structure is:

22

ARISTADA is available as a white to off-white sterile aqueous extended-release injectable suspension for intramuscular injection in the following strengths of aripiprazole lauroxil (and deliverable volumes from a single-dose pre-filled syringe): 441 mg (1.6 mL), 662 mg (2.4 mL), 882 mg (3.2 mL) and 1064 mg (3.9 mL). The inactive ingredients include sorbitan monolaurate (3.8 mg/mL), polysorbate 20 (1.5 mg/mL), sodium chloride (6.1 mg/mL), sodium phosphate dibasic anhydrous (0.62 mg/mL), sodium phosphate monobasic dihydrate (0.52 mg/mL) and for injection.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Aripiprazole lauroxil is a of aripiprazole. Following intramuscular injection, aripiprazole lauroxil is likely converted by enzyme-mediated hydrolysis to N-hydroxymethyl aripiprazole, which is then hydrolyzed to aripiprazole. The mechanism of action of aripiprazole in schizophrenia is unknown. However, efficacy could be mediated through a combination of partial activity at D2 and 5-HT1A receptors and antagonist activity at 5-HT2A receptors.

12.2 Pharmacodynamics

Aripiprazole exhibits high affinity for dopamine D2 and D3 (Kis 0.34 and 0.8 nM respectively), serotonin 5-HT1A and 5-HT2A receptors (Kis 1.7 and 3.4 nM respectively), moderate affinity for dopamine D4, serotonin 5-HT2C and 5-HT7, alpha1-adrenergic and H1 receptors (Kis 44 nM, 15 nM, 39 nM, 57 nM, and 61 nM, respectively), and moderate affinity for the serotonin reuptake site (Ki 98 nM). Aripiprazole has no appreciable affinity for muscarinic receptors (IC50 > 1000 nM). Actions at receptors other than D2, 5-HT1A, and 5-HT2A could explain some of the adverse reactions of aripiprazole (e.g., the orthostatic hypotension observed with aripiprazole may be explained by its antagonist activity at adrenergic alpha1 receptors).

12.3 Pharmacokinetics ARISTADA is a prodrug of aripiprazole and its activity is primarily due to aripiprazole, and to a lesser extent dehydro-aripiprazole (major metabolite of aripiprazole), which has been shown to have affinities for D2 receptors similar to aripiprazole and represents 30-40% of the aripiprazole exposure in plasma.

23 Absorption After single intramuscular injection the appearance of aripiprazole in the systemic circulation starts from 5 to 6 days and continues to be released for an additional 36 days. Aripiprazole concentrations increase with consecutive doses of ARISTADA and steady-state four months following treatment initiation. The concentration-time course of dehydro-aripiprazole followed that of aripiprazole. With the addition of a single intramuscular injection of ARISTADA INITIO and 30 mg oral aripiprazole at the time of the first ARISTADA dose, aripiprazole concentrations reach relevant levels within 4 days. Similarly, with the addition of the oral supplementation for 21 days at the time of the first ARISTADA dose, aripiprazole concentrations reach relevant levels within 4 days. Aripiprazole exposure was similar for deltoid and gluteal intramuscular injections of 441 mg ARISTADA, thus are interchangeable. Administration of 882 mg every 6 weeks or 1064 mg every 2 months results in plasma aripiprazole concentrations that were similar to exposure with 662 mg monthly and are within the range provided by doses of 441 mg monthly and 882 mg monthly. The doses of 441 mg monthly and 882 monthly showed a similar clinical response to each other. Distribution Based on population pharmacokinetic analysis, the apparent volume of distribution of aripiprazole following intramuscular injection of ARISTADA was 268 L, indicating extensive extravascular distribution following absorption. At therapeutic concentrations, aripiprazole and its major metabolite are greater than 99% bound to serum , primarily to albumin. In healthy human volunteers administered 0.5 mg/day to 30 mg/day oral aripiprazole for 14 days, there was dose-dependent D2 receptor occupancy indicating penetration of aripiprazole in humans. Elimination Metabolism The biotransformation of ARISTADA likely involves enzyme-mediated hydrolysis to form N-hydroxymethyl-aripiprazole, which subsequently undergoes hydrolysis to aripiprazole. Elimination of aripiprazole is mainly through hepatic metabolism involving CYP3A4 and CYP2D6. [see Dosage and Administration (2.4)]. The mean aripiprazole terminal elimination half-life ranged from 53.9 days to 57.2 days after monthly, every 6-week and every 2 month injections of ARISTADA. The significantly longer aripiprazole apparent half-life compared to oral aripiprazole (mean 75 hours) is attributed to the dissolution and formation rate-limited elimination of aripiprazole following ARISTADA administration. Studies No specific drug interaction studies have been performed with ARISTADA. The drug interaction data provided below is obtained from studies with oral aripiprazole.

24 Effects of other drugs on the exposures of aripiprazole and dehydro-aripiprazole are summarized in Figure 1 and Figure 2, respectively. Based on simulation, a 4.5-fold increase in mean Cmax and AUC values at steady-state is expected when extensive metabolizers of CYP2D6 are administered with both strong CYP2D6 and CYP3A4 inhibitors. After oral administration, a 3-fold increase in mean Cmax and AUC values at steady-state is expected in poor metabolizers of CYP2D6 administered with strong CYP3A4 inhibitors. Figure 1: The Effects of Other Drugs on Aripiprazole Pharmacokinetics

25 Figure 2: The Effects of Other Drugs on Dehydro-aripiprazole Pharmacokinetics

The effects of aripiprazole on the exposures of other drugs are summarized in Figure 3. Figure 3: The Effects of Oral Aripiprazole on Pharmacokinetics of Other Drugs

26 Specific Population Studies A population pharmacokinetic analysis showed no effect of sex, race or smoking on ARISTADA pharmacokinetics [see Use in Specific Populations (8.8)]. Exposures of aripiprazole and dehydro-aripiprazole using oral aripiprazole in specific populations are summarized in Figure 4 and Figure 5, respectively. Figure 4: Effects of Intrinsic Factors on Aripiprazole Pharmacokinetics

27 Figure 5: Effects of Intrinsic Factors on Dehydro-aripiprazole Pharmacokinetics

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis Lifetime carcinogenicity studies have not been conducted with aripiprazole lauroxil. Lifetime carcinogenicity studies with oral aripiprazole have been conducted in ICR mice and in Sprague-Dawley (SD) and F344 rats. Aripiprazole was administered for 2 years in the diet at doses of 1, 3, 10, and 30 mg/kg/day to ICR mice and 1, 3, and 10 mg/kg/day to F344 rats (0.2 to 5 times and 0.3 to 3 times the oral MRHD of 30 mg/day based on mg/m2, respectively). In addition, SD rats were dosed orally for 2 years at 10, 20, 40, and 60 mg/kg/day (3 to 19 times the oral MRHD based on mg/m2). Aripiprazole did not induce tumors in male mice or rats. In female mice, the incidences of pituitary gland adenomas and mammary gland adenocarcinomas and adenoacanthomas were increased at dietary doses which are 0.1 to 0.9 times human exposure at the oral MRHD based on AUC and 0.5 to 5 times the oral MRHD on mg/m2 basis. In female rats, the incidence of mammary gland fibroadenomas was increased at a dietary dose which is 0.1 times human exposure at the oral MRHD based on AUC and 3 times the oral MRHD on mg/m2 basis; and the incidences of adrenocortical carcinomas and combined adrenocortical adenomas/carcinomas were increased at an oral dose which is 14 times human exposure at oral MRHD based on AUC and 19 times the oral MRHD on mg/m2 basis. Proliferative changes in the pituitary and mammary gland of rodents have been observed following chronic administration of other antipsychotic agents and are considered

28 prolactin-mediated. The relevance for human risk of the findings of prolactin-mediated endocrine tumors in rodents is unknown. Mutagenesis Aripiprazole lauroxil was not mutagenic in the in vitro bacterial reverse mutation assay or clastogenic in the in vitro chromosome aberration assay in human peripheral blood lymphocytes. Aripiprazole and its metabolite (2,3-DCPP) were clastogenic in the in vitro chromosome aberration assay in Chinese hamster lung (CHL) cells both in the presence and absence of metabolic activation. The metabolite, 2,3-DCPP, produced increases in numerical aberrations in the in vitro assay in CHL cells in the absence of metabolic activation. A positive response was obtained in the oral in vivo micronucleus assay in mice; however, the response was due to a mechanism not considered relevant to humans. Impairment of Fertility Animal Data for Aripiprazole Lauroxil In a rat fertility study, aripiprazole lauroxil was administered intramuscularly. Males were treated with doses of 18, 49, or 144 mg /animal, which are approximately 0.4 to 3 times the MRHD of 1064 mg on mg/m2 basis, on Days 1, 21, and 42 prior to and through mating; females were treated at these doses, which are approximately 0.6 to 5 times the MRHD on mg/m2 basis, once 14 days prior to mating. In females, persistent diestrus was observed at all doses and the mean number of cycles was significantly decreased at the highest dose together with an increase in the copulatory interval (delay in mating). Additional changes at the high dose included slight increases in corpora lutea and pre-implantation loss, decline in mating, fertility, and fecundity indices in females and lower mating and fertility indices in males. Animal Data for Aripiprazole Female rats were treated with oral aripiprazole doses of 2, 6, and 20 mg/kg/day, which are 0.6 to 6 times the oral MRHD of 30 mg/day on mg/m2 basis, from 2 weeks prior to mating through day 7 of gestation. Estrous cycle irregularities and increased corpora lutea were seen at all doses, but no impairment of fertility was observed. Increased pre-implantation loss was found at 2 and 6 times the oral MRHD on mg/m2 basis and decreased fetal weight was noted at the highest dose which is 6 times the oral MRHD on mg/m2 basis. Male rats were treated with oral aripiprazole doses of 20, 40, and 60 mg/kg/day, which are 6 to 19 times the oral MRHD on mg/m2 basis, from 9 weeks prior to and through mating. Disturbances in spermatogenesis at the highest dose and prostate atrophy at the mid and high doses were noted which are 13 and 19 times the oral MRHD on mg/m2 basis, but no impairment of fertility was observed.

13.2 Animal Toxicology and/or Pharmacology Intramuscular administration of aripiprazole lauroxil to rats and dogs was associated with injection site tissue reactions at all doses in rats treated up to 6 months at doses of 15, 29, and 103 mg/animal (which are approximately 0.3 to 2 times and 0.5 to 3 times the MRHD of 1064 mg on mg/m2 basis in males and females, respectively) and in dogs treated up to 9 months

29 at doses of 147, 662, and 2058 mg/animal (which are approximately 0.5 to 6 times and 0.6 to 8 times the MRHD in males and females, respectively on mg/m2 basis). These injection site tissue reactions consisted of localized granulomatous and formation. Transiently impaired limb function and swelling occurred in dogs. The did not completely resolve 2 months following the last injection in the 6 month rat study and 4 months following the last injection in the 9 month dog study (the low dose groups were not examined for reversibility in these studies). Orally administered aripiprazole produced retinal degeneration in albino rats in a 26-week chronic toxicity study at a dose of 60 mg/kg, which is 19 times the oral MRHD of 30 mg/day on mg/m2 basis, and in a 2-year carcinogenicity study at doses of 40 mg/kg and 60 mg/kg, which are 13 and 19 times the oral MRHD on mg/m2 basis and 7 to 14 times human exposure at the oral MRHD based on AUC. Evaluation of the retinas of albino mice and of monkeys did not reveal evidence of retinal degeneration. Additional studies to further evaluate the mechanism have not been performed. The relevance of this finding to human risk is unknown.

14 CLINICAL STUDIES Efficacy of ARISTADA (441 mg monthly and 882 mg monthly) The efficacy of ARISTADA in the treatment of patients with schizophrenia was established, in part, on the basis of efficacy data from trials with the oral formulation of aripiprazole. In addition, the efficacy of ARISTADA was established in a 12-week, randomized, double-blind, placebo-controlled, fixed-dose study in adult patients with schizophrenia meeting DSM-IV TR criteria [Study 1, n = 622; 207 (ARISTADA 441 mg monthly), 208 (ARISTADA 882 mg monthly), and 207 (placebo)]. After establishing tolerability to oral aripiprazole, patients received oral aripiprazole or placebo daily for the first 3 weeks. The intramuscular (IM) injections were administered on Days 1, 29 and 57. Efficacy was assessed using Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Improvement Scale (CGI-I): • The PANSS is a 30-item scale that measures positive symptoms of schizophrenia (7 items), negative symptoms of schizophrenia (7 items), and general psychopathology (16 items), each rated on a scale of 1 (absent) to 7 (extreme). Total PANSS scores range from 30 to 210. • The CGI-I rates improvement in mental illness on a scale of 1 (very much improved) to 7 (very much worse) based on the change from baseline in clinical condition. Eligible patients were 18 to 70 years of age with PANSS total score of 70 to 120 and a score of ≥4 for at least 2 of the selected Positive Scale items. Patients were also required to have a CGI-S score of ≥4. The primary efficacy variable was the change from baseline to endpoint (Day 85) in PANSS total score. Statistically significant separation from placebo on PANSS total score change was observed in each ARISTADA dose group (Table 11).

30 Table 11: Primary Efficacy Results

Primary Efficacy Measure: PANSS Total Score Study Mean Baseline LS Mean Change Placebo-subtracted Number Treatment Group Score (SD) from Baseline (SE) Differencea (95% CI) ARISTADA 441 mg Study 1 92.6 (10.2) -20.9 (1.4) -10.9 (-14.5, -7.3) monthlyb ARISTADA 882 mg 92.0 (10.8) -21.8 (1.4) -11.9 (-15.4, -8.3) monthlyb Placebo 93.9 (11.3) -9.8 (1.4) -- SD: standard deviation; SE: standard error; LS Mean: least-squares mean; CI: confidence interval, not adjusted for multiple comparisons. a Difference (drug minus placebo) in least-squares mean change from baseline. b Doses that are demonstrated to be effective. The visit-wise mean change from baseline on PANSS total score change for each treatment group is shown in Figure 6. Figure 6: Change from Baseline in PANSS Total Score

Abbreviations: AL= ARISTADA; PBO=placebo; PANSS=Positive and Negative Syndrome Scale. Vertical dotted line indicates end of oral supplementation. Subgroup analyses did not suggest any clear evidence of differential responsiveness in treatment outcome as a function of age, gender, race, or weight.

31 The secondary efficacy endpoint was defined as the CGI-I score at Day 85. Both ARISTADA treatment groups demonstrated statistically significantly better CGI-I scores versus placebo. Efficacy of ARISTADA 662 mg Monthly, 882 mg Every 6 Weeks and 1064 mg Every 2 Months The efficacy of ARISTADA 662 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months in the treatment of adults with schizophrenia was established by pharmacokinetic bridging which demonstrated that these dosing regimens resulted in plasma aripiprazole concentrations that are within the range provided by doses of 441 mg monthly and 882 mg monthly. As depicted in Figure 6, the doses of 441 mg monthly and 882 mg monthly showed clinical responses similar to each other in the ARISTADA placebo-controlled trial.

16 HOW SUPPLIED/ STORAGE AND HANDLING 16.1 How Supplied ARISTADA extended-release injectable suspension is available in strengths of 441 mg in 1.6 mL, 662 mg in 2.4 mL, 882 mg in 3.2 mL and 1064 mg in 3.9 mL. The kit contains a 5-mL pre-filled syringe containing ARISTADA as a sterile white to off-white aqueous extended- release injectable suspension with safety needles. • The 441 mg strength kit (NDC 65757-401-03; light blue label) contains three safety needles; a 1-inch (25 mm) 21 gauge, a 1½-inch (38 mm) 20 gauge, and a 2-inch (50 mm) 20 gauge needle. • The 662 mg strength kit (NDC 65757-402-03; green label) contains two safety needles; a 1½-inch (38 mm) 20 gauge and a 2-inch (50 mm) 20 gauge needle. • The 882 mg strength kit (NDC 65757-403-03; burgundy label) contains two safety needles; a 1½-inch (38 mm) 20 gauge and a 2-inch (50 mm) 20 gauge needle. • The 1064 mg strength kit (NDC 65757-404-03; dark blue label) contains two safety needles; a 1½-inch (38 mm) 20 gauge and a 2-inch (50 mm) 20 gauge needle.

16.2 Storage Store at room temperature 20°C to 25°C (68°F to 77°F) with excursions permitted between 15°C and 30°C (between 59°F and 86°F).

17 PATIENT COUNSELING INFORMATION Advise patients to read FDA-approved patient labeling (Medication Guide).

32 Pathological Gambling and Other Compulsive Behaviors Advise patients and their caregivers of the possibility that they may experience compulsive urges to shop, intense urges to gamble, compulsive sexual urges, binge eating and/or other compulsive urges and the inability to control these urges. In some cases, but not all, the urges were reported to have stopped when the dose was reduced or stopped [see Warnings and Precautions (5.7)]. Neuroleptic Malignant Syndrome Counsel patients about a potentially fatal adverse reaction referred to as NMS that has been reported in association with administration of antipsychotic drugs. Advise patients to contact a healthcare provider or report to the emergency room if they experience signs or symptoms of NMS [see Warnings and Precautions (5.4)]. Tardive Dyskinesia Advise patients that abnormal involuntary movements have been associated with administration of antipsychotic drugs. Counsel patients to notify their healthcare provider if they notice any movements which they cannot control in their face, tongue, or other body part [see Warnings and Precautions (5.5)]. Metabolic Changes (Hyperglycemia and Diabetes Mellitus, Dyslipidemia, and Weight Gain) Educate patients about the risk of metabolic changes, how to recognize symptoms of hyperglycemia and diabetes mellitus, and the need for specific monitoring, including blood glucose, lipids, and weight [see Warnings and Precautions (5.6)]. Orthostatic Hypotension Educate patients about the risk of orthostatic hypotension (symptoms include feeling dizzy or lightheaded upon standing), particularly at the time of initiating treatment, re-initiating treatment, or increasing the dose [see Warnings and Precautions (5.8)]. Falls Advise patients and their caregivers of the possibility that they may experience somnolence, postural hypotension, or motor and sensory instability, which may lead to the risk of falls, particularly in patients with diseases, conditions, or medications that could exacerbate these effects [see Warnings and Precautions (5.9)]. Leukopenia/ Neutropenia Advise patients with a pre-existing low WBC count or a history of drug-induced leucopenia/neutropenia that they should have their CBC monitored while receiving ARISTADA [see Warnings and Precautions (5.10)]. Interference with Cognitive and Motor Performance Because ARISTADA may have the potential to impair judgment, thinking or motor skills, instruct patients to be cautious about operating hazardous machinery, including automobiles, until they are reasonably certain that ARISTADA therapy does not affect them adversely [see Warnings and Precautions (5.12)].

33 Heat Exposure and Dehydration Advise patients regarding appropriate care in avoiding overheating and dehydration [see Warnings and Precautions (5.13)]. Concomitant Medication Advise patients to inform their physicians if they are taking, or plan to take, any prescription or over-the-counter drugs, since there is a potential for interactions [see Drug Interactions (7)]. Pregnancy Advise patients that ARISTADA may cause extrapyramidal and/or withdrawal symptoms in a neonate and to notify their healthcare provider with a known or suspected pregnancy [see Use in Specific Populations (8.1)]. Pregnancy Registry Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ARISTADA during pregnancy [see Use in Specific Populations (8.1)].

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For additional information, visit www.ARISTADA.com or call 1-866-274-7823 Manufactured and marketed by: Alkermes, Inc. 852 Winter Street Waltham, MA 02451-1420

©2020 Alkermes, Inc. All rights reserved. ALKERMES® is a registered trademark of Alkermes, Inc., ARISTADA® is a registered trademark used by Alkermes, Inc. under license and ARISTADA INITIO® is a registered trademark used by Alkermes, Inc. under license. Printed in U.S.A.

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